On "Can a comprehensive lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema?" (Evidence in Practice).

On "Can a comprehensive lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema?":

We are members of a multidisciplinary lymphedema special interest group in northern Virginia. Our group includes physical therapists, occupational therapists, registered nurses, and massage therapists who are trained in the Vodder, LeDuc and Casley-Smith methods of complete decongestive therapy (CDT), which is sometimes referred to as comprehensive physical therapy or complex physical therapy (CPT). We would like to address several important concerns we have about the "Evidence in Practice" article in the March 2002 issue. These concerns fall into 3 general areas: the examination and treatment of the patient, the evidence gathered, and what we believe to be the disservice done to lymphedema therapists and our patients by publishing this article in a professional journal, which, therefore, implies a standard of practice.

In the patient interview, the author failed to ask questions essential to the history of any patient with lymphedema: when the lymphedema actually started, whether the infections triggered the lymphedema, what the nature of the swelling was, and whether there had been any previous intervention for the lymphedema.

In the examination, important issues were not addressed, including a clear location of the swelling, skin integrity, tissue texture, pitting, fibrosis, radiation changes, axillary web syndrome (also called cording), current signs of infection, and the presence and location of scars. The 11 standard sites of measurement noted by the author were not clear. What was the basis of the standard he cited? As lymphedema therapists, we take measurements at 4-cm intervals and then, utilizing the formula for finding the volume of a cone, we calculate the volume of the limb. The number of measurements, therefore, would depend on the length of the limb. Additional hand measurements also are taken to assess hand swelling. (1) There was no indication that the author is trained in these important aspects of assessing lymphedema.

In the third paragraph, the author stated, "the increase in limb size was consistent with chronic lymphedema secondary to radical mastectomy." Was a lymphoscintigraphy performed to allow for a definitive diagnosis? Was the patient tested for metastasis or recurrence of breast cancer and were these conditions ruled out? Was a Doppler ultrasound done to rule out a deep vein thrombosis? What was the stage of the lymphedema? These are important considerations before proceeding with treatment. When describing the components of an intervention program for this patient, the author vaguely and erroneously defined CPT as "some form of external compression ... and an exercise program." He left out the other components of CPT--manual lymphatic drainage (MLD), 24-hour compression (initially with short-stretch bandages), exercise with compression on the limb to maximize use of the muscle pump, and education in self-management and lymphedema precautions to minimize risk of infection. (2,3)

The author's description of the database used and how the search was conducted was very detailed, and it seems clear that researching data is his forte. The author's rationale for limiting his search to CINAHL is a concern. Much of the research on lymphedema and its treatment has been done in Europe and has been published in languages other than English. CINAHL will provide abstracts in English, but the full article is available only in its original published language. More importantly, CINAHL is limited to allied health professions and excludes medical journals. This automatically excludes many of the most important research studies on lymphedema treatment, which can be found in medical journals such as Lancet, Angiology, Lymphology, European Journal of Lymphology, Annals of Plastic Surgery, Oncology, American Journal of Medicine, and Archives of Surgery. The use of a database with these limitations appears to contradict the central purpose of the article, which is to illustrate how best to gather evidence for effective treatment.

The author's discussion of the selection of articles for review is disturbing because, of the 25 articles he found through his search, he chose only 3 articles, 2 of which were literature reviews, and he stated that he started by looking at the title "in the interest of time." He then stated that if he "could not adequately answer [his] question from these 3 articles, [he] could always return to the list of search results to read other articles." He later acknowledged that his review left important questions unanswered, but made his plan of care based on what he "felt ... was reasonable," without ever returning to his list of search results for more information. Doesn't this also contradict the notion of effective evidence gathering?

Regarding the issue of infection, which is central to the author's original question, a randomized trial with a control group that did not receive treatment for infection would be unethical, so it is unlikely that a study of this kind would be found. There are other articles that address the issue of infection related to lymphedema, (2,4) but the author's search was not broad enough to find them.

The clinical decision part of the article is the most troubling. On the basis of the second article reviewed, (5) the author accepted the idea that CPT is no more effective than a compression garment alone. He also made the statement based on a review of a level I study that

"this study did not find any additional benefit to adding manual lymph drainage and self-massage." The first study reviewed by the author indicated support for use of pneumatic compression pumps. (6) Yet the author decided to use a "comprehensive treatment regimen" that seemed to include all the components of CPT (without pneumatic pumps), despite the fact that his review of the evidence did not support this. After gathering the scientific evidence, he based his decision on treatment modalities on what he "felt was reasonable." Furthermore, the author implied that he would provide the MLD and compression bandaging; however, there was no indication that he was properly trained in these techniques. The implication is that special training is not needed, just some cursory exposure to the technique. Unskilled application of MLD and compression bandages can do more harm than good; therefore, treatment by a qualified therapist is essential.

The author stated that the results of his search for evidence indicated that the "combination of treatments [that] will provide optimal results remains in question." We disagree. We believe that a number of articles (2,4,7-12) support a truly comprehensive approach (in the form of qualified CPT) to lymphedema management. The author also showed a lack of appreciation for the proper training and qualifications in treating lymphedema. Lymphedema should not be considered a rehabilitation diagnosis but rather a medical diagnosis and should be treated as such. It should be managed much as diabetes is managed--on a medical level. The assessment and treatment of lymphedema requires specialized training. If a patient with lymphedema ends up in the hands of a non-skilled therapist who does not have a proper understanding of lymphedema (and in this case postmastectomy oncology as well), the outcome for the patient could be life-threatening.

Because this article appeared in a professional journal, it implies that this is the standard of practice for the profession. This is simply not so. There are qualified therapists providing the highest level of lymphedema treatment to our patients. This patient would have been better served by a referral to a trained lymphedema therapist. In conclusion, it is a disservice to the profession and to our patients to hold up the patient care described in this article as an acceptable standard of practice.

Paula D Levinson, PT, OCS, CLT-LANA
John F Beckwith, PT, CLT-LANA
Jennifer Willey, MPT, CLT/MLD
Cindy Fields, PT, CLT/MLD
Tom Eaton, PT, MS, CLT/MLD

References

(1) Casley-Smith JR. Measuring and representing peripheral oedema and its alterations. Lymphology. 1994;27:56-70.

(2) Ko DS, Lerner R, Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities. Arch Surg. 1998;133:452-458.

(3) The diagnosis and treatment of peripheral lymphedema: consensus document of the International Society of Lymphology Executive Committee. Lymphology. 1995;28:113-117.

(4) Boris M, Weindorf S, Lasinski B. Persistence of lymphedema reduction after noninvasive complex lymphedema therapy. Oncology (Huntingt). 1997;11(1):99-109.

(5) Harris SR, Hugi MR, Olivotto IA, et al. Clinical practice guidelines for the care and treatment of breast cancer, 11: lymphedema. Can Med Assoc J. 2001;164:191-199.

(6) Wozniewski M, Jasinski R, Pilch U, Dabrowska G. Complex physical therapy for lymphoedema of the limbs. Physiotherapy. 2001;87:252-256.

(7) Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg. 1989;22(6):505-515.

(8) Boris M, Weindorf S, Lasinski B. The risk of genital edema after external pump compression for lower limb lymphedema. Lymphology. 1998;31:15-20.

(9) Leduc A, Caplan I, Leduc O. Lymphatic drainage of the upper limb: substitution lymphatic pathways. European Journal of Lymphology. 1993;4:11-18.

(10) Johansson K, Lie E, Ekdahl C, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31:56-64.

(11) Hwang JH, Kwon JY, Lee KW, et al. Changes in lymphatic function after complex physical therapy for lymphedema. Lymphology. 1999;32:15-21.

(12) Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. 1992;93:543-548.

Former Editorial Board Member responds:

Levinson et al have raised 3 general concerns. Their first concern relates to the examination and management of the patient. The "Evidence in Practice" (EiP) series is intended to educate clinicians in strategies for locating peer-reviewed literature to guide their practice. It is a different type of article than a case report, which must provide extensive details of a patient's history, the results of the examination, the anticipated goals and expected outcomes, the interventions, and changes in the patient's status.

Because the case example did not provide the same level of detail as a case report, the information from the patient interview was deemed inadequate by Levinson and colleagues. From my reading of the background information, however, the lymphedema appeared to occur "over the past year" and seemed to be related to the patient's 3 infections. It also appeared that there was no previous treatment for the lymphedema. Levinson and colleagues also have suggested that there should have been more information in the examination (eg, skin integrity, tissue texture, presence of pitting or fibrosis, current signs of infection). I agree that this type of information would have added to our understanding of the patient's present condition, but it would not have changed the primary goal, which was to reduce the upper-extremity swelling.

Levinson et al are concerned that the measurement of limb circumference was not described in more detail. In fact, there is no standardized method for measuring lymphedema in the peer-reviewed literature. (1) Moreover, taking measurements at 11 sites is much more comprehensive than what has been recommended in recently published clinical practice guidelines on management of breast cancer-related lymphedema. (2)

The authors' second concern is that the EiP author gathered deficient evidence because he used the CINAHL database. In fact, 2 of the 3 articles on which the author chose to base his intervention decisions (2,3) were published in journals that are also indexed through MEDLINE. Thus, Levinson and colleagues' statement that a CINAHL search excludes "medical journals" is inaccurate because the list of search results included the Canadian Medical Association Journal and the Journal of the National Cancer Institute--both respected medical journals read primarily by physicians. The purpose in choosing CINAHL was to access those physical therapy journals that are not included in Index Medicus (eg, Physiotherapy, Physiotherapy Canada) and to illustrate the diversity of resources available to physical therapists who are searching for evidence.

The authors of this letter were concerned that 2 of the 3 articles cited were "literature reviews." They, however, appear to have confused the definitions of literature reviews, systematic reviews, and clinical practice guidelines. In fact, one article cited was a systematic review (3) and the other was a clinical practice guideline by a nationally recognized group of lymphedema experts, which included a physical therapist, a radiation oncologist, a medical oncologist, and a physician who is living with lymphedema. (2) I would refer the authors to the article by Scalzitti, (4) which defines and differentiates systematic reviews and clinical practice guidelines.

The third concern raised by Levinson et al is that a "disservice" was done to lymphedema therapists and their patients through the publication of this article. In my experience as both a physical therapist and a recent health care consumer, evidence-based practice goes hand in hand with patient-centered care. To suggest that basing practice on recent and peer-reviewed scientific evidence, in the form of a systematic review and clinical practice guidelines, does a "disservice" to patients with lymphedema is a very frightening statement to be made by a group of health care professionals.

I owe the past 4 years of my life to the fact that my own oncologists were evidence-based practitioners. My cancer treatments (chemotherapy and radiation) were based on the best scientific evidence available (level I randomized controlled trials) published in well-respected, peer-reviewed journals (ie, Journal of Clinical Oncology and New England Journal of Medicine).

I urge Levinson and colleagues to contribute to the limited body of knowledge on management of lymphedema by producing case reports or single-subject research reports on some of their patients and submitting their results to a peer-reviewed journal.

Susan R Harris, PT, PhD
Professor
Division of Physical Therapy
The University of British Columbia
T-325-2211 Wesbrook Mall
Vancouver, BC V6T 2B5

References

(1) Megens A, Harris SR, Kim-Sing C, McKenzie DC. Measurement of upper extremity volume in women following axillary dissection for breast cancer. Arch Phys Med Rehabil. 2001;82:1639-1644.

(2) Harris SR, Hugi MR, Olivotto IA, et al. Clinical practice guidelines for the care and treatment of breast cancer, 11: lymphedema. Can Med Assoc J. 2001;164:191-199.

(3) Megens A, Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Phys Ther. 1998;78:1302-1311.

(4) Scalzitti DA. Evidence-based guidelines: application to clinical practice. Phys Ther. 2001;81:1622-1628.